Background Acetamiprid is a potent new first-generation neonicotinoid insecticide in agricultural practices. It is well described that it has low toxicity among animals and is lethal if consumed in large amounts. However, toxicity in humans is rarely reported in literature. Here, we describe acetamiprid toxicity complicated with severe lactic acidosis, myocardial ischemia, refractory hypotension, and severe hypokalemia in a middle-aged man who presented with deliberate self-harming with acetamiprid poisoning in Sri Lanka. Case presentation We describe a case of acute poisoning with an acetamiprid in a middle-aged Sri Lankan Tamil farmer for suicidal purposes following family conflicts with his wife. He presented with severe nausea, vomiting, and altered level of consciousness. He had electrocardiogram changes, hypoxia, and lactic acidosis. With intensive care management including ventilatory support, inotropic therapy along with intraarterial blood pressure monitoring, correction of acidosis, and administration of electrolytes, he made good clinical recovery. He was discharged without any further complications 6 days after ingestion of acetamiprid. Conclusions This case illustrates a rare, acute poisoning with acetamiprid in human, as well as its clinical manifestations and successful management with supportive therapy. This will be helpful for clinicians to identify clinical manifestations and to guide management of acute poisoning with acetamiprid in the future.

The saw-scaled viper ( Echis carinatus) is considered as a highly venomous snake in Sri Lanka. The clinical manifestations are localized pain and swelling, coagulopathy and renal impairment. Thrombotic microangiopathy is rarely reported as a complication of saw-scaled viper envenoming. The clinical manifestations of thrombotic microangiopathy include thrombocytopenia, microangiopathic haemolytic anaemia and acute kidney injury. The consumption coagulopathy of post-envenoming could be followed by a syndrome consistent with thrombotic microangiopathy. We describe a patient with thrombotic microangiopathy following saw-scaled viper systemic envenoming which was managed with antivenom and supportive therapy. The dead snake which was brought by patient was identified by medical professional as saw-scaled viper ( E. carinatus) based on morphological features. This case illustrates a rare manifestation thrombotic microangiopathy following saw-scaled viper envenoming.